Copyright This American Life from Chicago Public Radio. Posted with permission.
This American Life Episode Transcript
“More is Less”
Broadcast October 9, 2009
Ira Glass: I was in the kitchen, cooking some food for my dog, which I don’t say with pride—I don’t even
approve of people cooking for their dogs, but he’s got health problems, and without boring you with a lot of
details, there’s no getting around it, okay? And I was listening to Marketplace, which is actually the point
of this story I’m telling you. I was listening to the radio on Marketplace, and I heard this commentary by
one of their regular commentators, this conservative commentator David Frum, who said that new numbers
had just been released by the government showing that when you look at family incomes and what
happened to family incomes during the Bush presidency…
David Frum: George W. Bush has the worst economic performance of any two-term president
since the numbers were collected. Jimmy Carter did worse, but he only had one term.
Ira Glass: I asked Frum to come onto our show to talk about this finding.
David Frum: This is a little painful. I was part of the Bush Administration. In fact, I was part of
the Bush Administration’s economic team. [laughs] So I take this a little personally.
Ira Glass: But Frum says—and this was his point on Marketplace—that it’s important to understand why
Bush’s performance was so bad. Frum said that over those eight years, what employers actually paid for
each worker rose, and it rose a lot—25%. But…
David Frum: Employees received none of that money. The median American worker was earning
less in the year 2007 than that worker was earning—adjusting for inflation—in the year 2000.
And yet his employer was paying 25% more. So where did that money go? And the answer is it
all went to pay the rising cost of health care.
Ira Glass: The average cost of a health insurance policy for a family of four between 2000 and 2007 more
than doubled, from $6,000 to $13,000—a $7,000 climb. Coincidentally, during the boom years of
President Clinton, when Americans did so well, family incomes rose about that same amount--$6,500. This
is just how quickly health care costs are rising in this country. If you take into account health care, George
W. Bush stops being the worst two-term president in the modern era for family incomes.
David Frum: If you were to compare say President Bush’s performance to Harry Truman’s or the
Ford-Carter years, it looks good; if you compare it to the Clinton years, the Reagan years or the
Johnson years, it doesn’t look so good.
Ira Glass: So basically he’s somewhere in the middle. He’s kind of like…
David Frum: No, I would say the lower part of the middle. I mean, I don’t want to oversell the
Ira Glass: Rising health care costs are affecting everything in the economy. Rising health care costs are the
thing that’s driving our health care system off the rails. It’s what’s led so many people to being uninsured.
It’s making it hard for US businesses to compete. It’s gobbling up more and more of all spending in the
United States. I saw this number recently that said that at the current rate of growth, in just nine years, the
amount that the average American family’s going to spend on health care each year is going to be $38,000.
$38,000! That’s more than half of what family income will be that year. What was striking about that was
that this isn’t one of those projections that the government does looking at health care costs 75 years from
now showing how grim it’s going to be far in the future; this is nine years from now, at the current rate of
growth. Basically, this is going to happen. Half of our incomes are going to be going to health care very,
very soon, unless somebody does something. At this point we Americans spend 50% more on health care
than any country in the world, and the money isn’t buying us better health. If you look at the numbers,
when it comes to infant mortality, compared to other countries we are 45th—worse than Cuba. When it
comes to life expectancy, we’re 50th—behind, by the way, Bosnia and South Korea. And so today we ask
the question, “Why is this happening? What’s going on in health care that makes it so impossible to hold
costs down?” We’re tackling these questions now, this week, as health care’s being debated in
Washington, because fixing our health care system means fixing two different things—getting more people
covered by insurance, and slowing the increases in health care costs. And the bills on Capitol Hill right
now seem much more about solving the insurance problem than about controlling costs. So we’re going to
do something we’ve never done—we’re going to do two shows about this, this week and next week. This
is a co-production we’re doing with NPR News. Next week, the most entertaining hour, I guarantee, that
you’re ever going to hear on the insurance industry. This week we ask why costs keep rising. From
WBEZ Chicago, it’s This American Life, distributed by Public Radio International. I’m Ira Glass. Our
show today in four acts: Act One, Dartmouth Atlas Shrugged, in which we examine whether doctors are the
ones to blame for rising costs. Act Two, Every CAT scan has nine lives, in which we wonder if patients
are the problem. Act Three, Who Would Win In A Fight Between A Polar Bear and an Insurance
Company? Is the problem the insurance companies? And Act Four, Now What? In which we learn what
the new health care bills do to fix all this, if they do anything. Stay with us.
Ira Glass: Act one, Dartmouth Atlas Shrugged. There are all kinds of reasons that health care costs have
risen so quickly over the last few decades. We have higher administrative costs than other countries,
because our health care system, with its insurers and providers is so complicated. We use more expensive,
high-tech gear. Our drugs cost more. But there’s a whole school of thought that blames a lot of the rising
costs on doctors, prescribing drugs that people don’t really need, doing too many procedures. And the
reason people think this all goes back to the work of one person, a health researcher named Jack Wennberg.
NPR science correspondent Alix Spiegel explains what that’s all about.
Alix Spiegel: To understand the work of Jack Wennberg, let’s start with one patient and one medical
problem: a young woman with a sharp pain in her lower uterus.
Roxanne Trembly: I was having a lot of problem, just a constant ache right here that never went
away, and my boss kept saying, “You should go get that checked, you should go get that
checked,” because I was doubling right over. It was like a really, really deep ache all the time.
Alix Spiegel: In 1974 Roxanne Trembly was 29 years old, a single mom living in a small apartment in
Lewiston, Maine. Because Roxanne was the only one supporting her young daughter, she had to be able to
work, and the pain was getting in the way—the pain was a problem. So Roxanne went to see her
gynecologist, a nice man who did a short exam, and then kindly explained that Roxanne would need an
operation. Three weeks later Trembly had her uterus and ovaries removed—a total hysterectomy.
Roxanne Trembly: It was what he called “the seed of cancer.” It wasn’t cancer, but it had the
potential of developing into it.
Alix Spiegel: Now, Roxanne didn’t mind losing her uterus. She never planned to get married or have kids
again. But she was slightly surprised that her doctor had been so quick, and before surgery hadn’t taken
any x-rays or anything.
Roxanne Trembly: No pictures. No.
Alix Spiegel: He just felt you were—
Roxanne Trembly: And based what I told him, that it should come out.
Alix Spiegel: 29 years old is pretty young for a hysterectomy, but in the mid-‘70s in Lewiston, Maine, lots
of women were getting them. Roxanne herself knew a bunch.
Roxanne Trembly: My boss that I had when I worked at K-mart, she had one shortly after I did.
One of my friends that I’ve had since I was six years old, she lives right five minutes from here,
she had one. Just about anybody you talked to would say, “Oh, I had a hysterectomy. Oh yeah, so
I did, so-and-so did mine,” or, I just remember there was a lot of them. I do remember that.
Alix Spiegel: Now, most Lewiston women, including Roxanne, weren’t suspicious about the
hysterectomies, and this is where Jack Wennberg’s research comes in. Until Jack Wennberg made
Lewiston and its hysterectomies famous, no one had even noticed. But in the late ‘70s Wennberg published
a paper, a study of health care in Maine, and in it he showed that an unusually large number of women in
Lewiston were having their uterus removed. He projected that 70% would have a hysterectomy by age 70,
while a couple towns over the number was much smaller: 25%. That paper was one of a series of studies of
Maine and Vermont published by Wennberg in the ‘70s and ‘80s, studies which ultimately completely
transformed our understanding of what’s going on in health care in this country, which is how come I
ended up in Wennberg’s dining room.
Alix Spiegel: Hello, hello…
Alix Spiegel: This is me trying to set the levels on my recording equipment. To do this, I asked Wennberg
what I ask most people: “Could you say a little something?” This is what I got…
Jack Wennberg: [German]
Alix Spiegel: 19th century German poetry. Apparently, for fun in college, Wennberg committed foreign
verse to memory. Wennberg’s that kind of guy—the kind of guy whose side projects tend to be unusually
rigorous. This was certainly the case in health care. You see, when Wennberg started out in the late ‘60s,
what he was trying to do was improve medicine in the State of Vermont, get better medical services to rural
communities. He’d gotten a grant to overhaul Vermont’s health care system, but because Wennberg is
such a thorough type of fellow, he made a pretty extreme decision: He decided he’d try to collect
information about every medical transaction of every person in every town in the whole state. That way
he’d known what was going on.
Jack Wennberg: What was going on in home health agencies, what was going on in nursing
homes, hospitals, doctor’s offices, and we need to know for each patient what their diagnosis is,
what their treatment was, how much money was spent, and what the outcomes were insofar as we
could actually measure them.
Alix Spiegel: Now, to collect these records Wennberg hired a bunch of researchers, people dubbed “the pit
crew,” who year after year were sent out to medical records rooms to collect records. It was a massive
undertaking—every medical transaction in the State of Vermont. It took two years of road trips just to
collect the records for 1969. But once he had all the information, Wennberg began to slice it and dice it in
all kinds of ways. And what immediately jumped out was that medicine from town to town in Vermont
was practiced in entirely different ways.
Jack Wennberg: As soon as we set out to do the analyses, we began to see these extraordinary
Alix Spiegel: In one town, say 50% of the men would have a prostate procedure, but in another town only
30 miles away, only 15% would.
Alix Spiegel: Ditto with mastectomies, hemorrhoid removal, back surgery. Basically, town after town was
a version of Lewiston, Maine, in the sense that some procedures might be incredibly numerous, or
conversely, incredibly rare.
Jack Wennberg: It just didn’t make sense. I mean, we lived right on the boundary between Stow
and Waterbury Center, Vermont, and if my kids had been going to the school system in Stow, they
would’ve had a 75% chance of getting their tonsils out. If they’d gone to the Waterbury school,
where they actually did, it was about 20%.
Alix Spiegel: So what was going on? Why the differences? Well, there are two possible explanations. The
first explanation is that it was the doctors; doctor behavior was somehow to blame. The second was that it
was the patients; that people in some areas were just much sicker than people in other areas, or maybe they
just wanted more services for some reason. Which brings us back to the City of Lewiston, Maine, and yet
another woman who had a hysterectomy.
Carol Bradford: My little dogs are freakin’ here. [laughs]
Alix Spiegel: Oh, hi there, little dogs.
Carol Bradford: Come in. You found me!
Alix Spiegel: A couple miles down the way from Roxanne Trembly, on a quiet Lewiston street, is the home
of Carol Bradford. Carol is another Lewiston woman who had her uterus removed in the 1970s. She had
fibroids, and like Roxanne, she’s happy with the result. But when I asked, Bradford had a theory about the
high hysterectomy rate in Lewiston back then. Lewiston, she explained, is mostly Catholic.
Carol Bradford: Some women were having too many children. You know, there are families here
with 10, 12 children. It’s a possibility that women came to the point where they just really
couldn’t deal with any more children, you know? And were begging the doctors to do something
about it. You know, that’s my personal opinion.
Alix Spiegel: Not just her opinion. Most people assume that when you go into a doctor’s office, the doctor
is simply responding—responding to sickness in your body; responding to the needs and concerns you
have. But in the studies he did in Vermont and Maine, Wennberg demonstrated that it’s a lot more
complicated than this. The women of Lewiston weren’t having more hysterectomies because more of them
were Catholic or because more of them were sick. Wennberg showed that in terms of sickness and
demographics, the populations of the communities in states like Maine and Vermont were actually
incredibly homogenous, which according to Jack Wennberg could mean just one thing: It wasn’t the
Jack Wennberg: It wasn’t true, it wasn’t correct, because we could easily see that it wasn’t that
patients were different between regions, so it wasn’t illness that was driving this; this must be
coming from the provider side.
Alix Spiegel: “The provider side” –the doctors; that was the first insight—that it was doctors, not patients
that drove medical consumption, and that there are all kinds of things that influence the decisions a doctor
makes when you go into his office. Sickness plays a role, but a much smaller role than we originally
Alix Spiegel: So what are the things that influence doctor decisions? To answer this question I went back
to Maine to talk to doctors themselves, doctors who explained that the work of Jack Wennberg inspired a
small revolution in the state. You see, after Wennberg published a paper on his early discoveries, a small
group of Maine doctors gathered to take action. They decided that physicians in Maine should and could
themselves figure out why these strange geographical variations in care were taking place, and the best way
to do that, this group figured, was to get all the doctors in Maine to sit down on a regular basis, look at
Maine city by city, and then hash out together why the care they were giving was so different. Bob Keller
is a back doctor who worked on this project, and he told me that in the beginning there was only one small
problem with the plan—many of the doctors in Maine hated it.
Bob Keller: Number one, they were insulted, they were angry. Their judgment was being
challenged; that was not allowed. There were variable responses. In some cases they just didn’t
believe it, and they would try to find holes in the data. One of the classics: “Oh, we have more
worker’s compensation here; we have more heavy industry here.” And we were able to work
through most of those things and demonstrate that wasn’t the case. But they would, “Our
population’s older; more of them need prostatectomies.” Well, we adjust for age, so that’s not an
argument anymore. And some doctors never could deal with that, and they would leave the study
groups. They just said, “This is baloney, we’re not going along with this.”
Alix Spiegel: But in time, says Keller, many doctors did warm to these ideas.
Bob Keller: They began to accept the data, and they began to accept that indeed, different
physicians were using different thought processes or decision-making processes in dealing with
Alix Spiegel: And so in the state of Maine, for years there was this incredible experiment. Four or five
times a year each medical specialty got together for a kind of Talmudic dissection of doctor choice,
conducted by the doctors themselves. They wanted to look at all of the differences, figure out why they
existed, and then try to bring their medical decisions in line with one another. They figured that by doing
this they could eliminate unnecessary care. Now, when talking in these groups, the Maine doctors usually
seemed to agree on what criteria they would use for making treatment decisions. So for instance, everyone
agreed that you only operate on a back after there had been three months of pain. But when they went back
to the data, it showed that in the privacy of their own offices many doctors were doing something
completely different. Why? One possible reason was fear of lawsuits. Some doctors felt that criteria be
damned—if they didn’t do every possible thing they might get sued. Another was temperament—some
doctors were just much more eager to take action. Then there was the role of medical culture—in some
communities it had evolved over time that, let’s say when a kid got a temperature of 102, he was sent to the
hospital, while in the next town over kids with that temperature were advised to just stay home. And then
there was the number of doctors in a community. One of the many doctors I talked to while I was in Maine
was this eye specialist named Frank Reed. He’s another doc who participated in these groups, and he told
me this story:
Frank Reed: My old partner that I joined here in 1971 was asked by a friend of his, “You know, at
what level of vision do you do a cataract operation?” and he said, “Well, if there’s one
ophthalmologist in town, it’s 20/200.”
Alix Spiegel: 20/200 is pretty bad vision.
Frank Reed: “If there are two ophthalmologists in town it’s 20/80.”
Alix Spiegel: Not so bad vision.
Frank Reed: “If there are three ophthalmologists in town, it’s 20/40.”
Alix Spiegel: Pretty good vision. In other words, the criteria easily shifts. According to later work done by
Jack Wennberg, the number of doctors in an area can influence the amount of medical services consumed.
The more doctors, the more appointments, the more procedures, the more money spent. You could actually
see this dynamic especially clearly during the ‘70s, because to drive down costs in medicine, the federal
government created a program to send more people to medical school. The theory was that when there are
more doctors, doctors would be forced to drop their prices to compete for patients—basic economics. But
that’s not what happened. The doctors just adjusted their criteria for doing stuff and had the patients they
had come in more often, because in health care supply drives demand. So when the doctors and clinics
increases, the demand for medical services goes up—often, Frank Reed says, for a completely innocent
Frank Reed: I don’t want to be sitting on my thumbs all the time; I want to be busy. And that may
unconsciously loosen my criteria for doing a particular procedure.
Alix Spiegel: Which brings us finally to the subject which, incredibly, was never ever discussed during the
nearly 20 years the doctors met: money; specifically, the idea that doctors might be prescribing more visits
and more procedures so that they could make more money. Frank Reed and Bob Keller told me that this
subject was completely verboten.
Doctor: We didn’t want to talk about money; that’s something that we wouldn’t want to
acknowledge because it would’ve been a showstopper. I mean it would’ve then gone right to the
question of greed, and you’re not going to keep a doc at the table if you say, “You’re greedy.”
Alix Spiegel: Doctors are uncomfortable acknowledging the world of money, but every doctor I talked to
admitted it affects medical decision-making, including Gordon Smith, head of the Maine Medical
Gordon Smith: Of course it does. That’s just common sense, that’s human nature. The payment
system is an important influence.
Alix Spiegel: You see, the majority of doctors in this country are not on salary, but are paid for each thing
they do, à la carte. That’s what they mean when they say “fee for service,” a phrase you’ve probably heard
a lot. And the way fee for service affects doctor behavior is clear. Gordon Smith:
Gordon Smith: If you pay people more, the more things they do, they’re going to do more things.
Alix Spiegel: Bob Keller points to his own specialty. He’s a back doctor, and says one of the most popular
operations among back doctors these days is this complicated procedure called an instrumented fusion.
When a patient has a back problem, the doctor can go in and insert metal rods. Keller says in the old days
the doctor used a much simpler and safer operation, but the new, more complicated one costs more.
Bob Keller: Surgeons could charge more because they were doing these complicated procedures.
And so they were putting the screws in, they billed for putting the screws; they were putting the
plates in, they billed for putting the plates in. Doing all these things. In the old days a fusion was
a very much simpler operation with no external devices. It was all done with the patient’s own
tissues and bone. So you had a whole new high-tech procedure that was enormously attractive to
spine surgeons, and it literally took off in this country. At the same time, as most good spine
surgeons will admit, they had no research to support what they were doing.
Alix Spiegel: In fact, says Keller, the one high-quality study that did exist wasn’t so positive.
Bob Keller: It showed that it isn’t so great, actually, as people thought it was, and they also
showed that, interestingly enough, that the old-fashioned non-instrumented fusion was as
successful as the instrumented fusion, which was a real blow.
Alix Spiegel: And here in miniature is one of the big problems with the way our current system is set up.
It’s a problem some call “more is not better.” Doctors exist in a system that encourages, and really because
of their fear of malpractice suits, actually forces them to do more—more surgery, more tests, more stuff of
every kind. And while most Americans just assume that more care is good, it turns out that more isn’t
always better for patients, because every time you get a medical procedure you risk the possibility of
complications and doctor error. In 2003 there was this enormous landmark study published by a Jack
Wennberg protégé named Elliott Fisher. He compared areas throughout the United States, areas where
elderly got relatively small amounts of health care services, to areas where elderly people got a lot of health
care services—a lot. Here’s Fisher:
Elliott Fisher: The patients in the high-spending regions were getting about 60% more care. So,
you know, 60% more days in the hospital, twice as many specialist visits. And yet when you
followed patients for up to five years, the mortality rate—whether you were poor, rich, urban or
rural—if you lived in one of these higher-intensity communities, your survival was certainly no
better, and in many cases, worse.
Alix Spiegel: After Wennberg’s original work in Vermont and Maine, a group of health care researchers set
up a shop at Dartmouth College and created something called the Dartmouth Atlas of Health Care,
basically the countrywide version of what Wennberg did in New England. The huge warehouse of data
compiled by these researchers has led to a lot of insights about our system, including this very disturbing
statistic that you sometimes hear in the health care debate: They’ve estimated that about one-third of the
medical care delivered in this country is unnecessary—one-third. Doctors in hospitals doing things to you
and me that we don’t need—stuff that doesn’t make us any more healthy. Care delivered by a system that
pushes doctors to do more when less is probably better.
Ira Glass: Alix Spiegel. Coming up, patients are told that they should do with less, that the test or
procedure that they want for themselves is unnecessary. And surprise—they are not too happy about it.
That’s in a minute from Chicago Public Radio and Public Radio International when our program continues.
It’s This American Life, I’m Ira Glass. Each week on our show, of course, we choose a theme, bring you
different kinds of stories on that theme. Today’s show: More Is Less. This is the first of two shows that
we’re going to be doing this week and next explaining the health care system, or parts of it anyway. Today
we’re asking the question, “Why are health care costs rising so much that they threaten our entire
economy?” We’ve arrived at act two of our show—Act Two: Every CAT Scan Has Nine Lives. This
summer, at a press conference President Obama described how he wants to slow the increase in health care
costs. He’s going to do it by having patients everywhere adjust a bit.
President Obama: They’re going to have to give up paying for things that don’t make them
healthier. Why would we want to pay for things that don’t work?
Ira Glass: Of course, when he says it that way, it sounds like it could not be easier. According to the
Dartmouth Atlas of Health, as you’ve just heard before the break, one-third of medical spending is on
treatments and tests that are not actually necessary, and in some cases may actually harm us, and President
Obama’s stimulus package devotes $1 billion to studying and determining which procedures those are. So
let’s just eliminate the stuff that doesn’t work, right? Well, one of our producers, Lisa Pollak, explains why
in practice that is not so easy to do.
Lisa Pollak: In the spirit of the president’s advice, here’s a story about what happened at one hospital when
one doctor tried to resist ordering a test for a patient: The patient was a teenage girl who’d been in a minor
car wreck. As a precaution she was brought into the ER on a backboard with one of those collars around
her neck. The doctor was Jerome Hoffman. He’s a professor of emergency medicine at UCLA. And the
first thing he needed to do was rule out the risk of an injury to the girl’s cervical spine. He was able to do
this without taking an x-ray, because when he examined the girl, her condition matched this list of five
criteria: For instance, she had no tenderness in the middle of the back her neck that indicate to doctors
when a fracture is extremely unlikely. Hoffman told the girl’s mother that her daughter was fine—no need
for an x-ray—and the mother seemed okay with this.
Jerome Hoffman: But a couple of minutes later the dad showed up.
Lisa Pollak: Dr. Hoffman.
Jerome Hoffman: And the dad was a very tall, very powerful figure who was very upset and spoke
very loudly. And he also happened to mention that he was a lawyer and that there would be
consequences for any error that we made. And he said that he wanted to get not just an x-ray, but
a CAT scan of her neck.
Lisa Pollak: A CAT scan, which is not only more expensive than an x-ray, but uses much more radiation.
Jerome Hoffman: So I tried to explain to him that, A, she didn’t really need the x-ray or the CAT
scan, and B, that there was some harm with it. In fact, if you do 1,000 CAT scans to a young
woman like this, there’s a pretty good chance that some small number—one, two, something like
that—may have harm from it, and the harm is not trivial harm; it’s important harm. She could get
a cancer of her thyroid that, in 15, 20 years, might actually be fatal. So while I can’t say with
100% certainty that her neck was fine, I was pretty sure—99.9%, at least, in my judgment—it
would be more harmful to her to do the test for her.
So I tried to explain this to the dad and I tried to be really nice and patient. But he was having
none of it. He said things like, “You will do a CAT scan,” and then I said to him something that
actually I had long known, but it never crystallized for me exactly in this way until that moment. I
said to him, “You know, for me it really is the right thing to do the CAT scan.” I said, “You
know, if I don’t do the CAT scan, you’re probably going to lodge a complaint about me; if I do the
CAT scan you’re going to be really happy with me.” I said, “In addition, I’m almost certain that
your daughter is fine, but there’s maybe one in a million chance that she isn’t, that there really is a
hidden fracture and I’m missing it. And if that’s the case, the CAT scan will save my butt. And
on the other hand, if I do the CAT scan and your daughter gets a cancer 20 years from now, no one
will blame me.” I said, “In addition, I’m spending a lot of time talking to you here that I need to
be going doing other things. If I got the CAT scan, I could do it in a second. It would be done
with, it would be easy,” and I said, “Finally, the really strange thing is that I’ll get paid more if I
do the CAT scan, because the way that bills are made, you get paid more for more complex
patients, and the insurance companies of the world think that it proves that the patient was more
complex and more difficult if you had to do a CAT scan.” So everything about this was pushing
me to do the CAT scan. I said that to him. I said, “There’s only one problem, which is that when
I decided to become a doctor, I made a pledge, and the pledge was that I would put my patients’
interests in front of my own interest.” And in this case, my judgment was that it was not in my
patient’s interest to do the CAT scan, and therefore I can’t do it. And it was really strange. I mean
it was interesting because this big guy, very powerful guy who had been really yelling and angry
and screaming, his jaw dropped and he was silent. He didn’t know what to say.
Lisa Pollak: And you didn’t do the CAT scan.
Jerome Hoffman: Oh no. No. That was the end of the story. I hope it’s the end of the story. It’s
been over a year now, and I haven’t gotten that famous embossed letter with a lawsuit, so I’m
assuming that everybody turned out fine.
Lisa Pollak: Hoffman told me this story is not an isolated example. Things like this happen all the time in
his department, whether it’s people wanting antibiotics for illnesses that antibiotics have been proven not to
help, or tests such as x-rays and CAT scans.
Jerome Hoffman: Where a patient thinks, “Well, don’t I need to be sure that I don’t have
appendicitis?” or this, that or the other thing. And really the right thing for the doctor to do is to
think, and in many cases, not to do any tests, at least not right now. There’s a place for tests and
there’s a place for interventions, but not in every case. And yet the incentive to the doctor is often,
“Just do everything.”
Lisa Pollak: And the truth is a lot of us like it that way. It’s hard to understand how doing everything could
be bad for us. We think, “Better safe than sorry; do everything possible.” In a study published earlier this
year, half the public believes someone’s getting unnecessary health care, but only 16% thought it was them.
We’re so wired to think that more health care is better that when someone suggests we might be better off
with less, it’s upsetting. Even daring to raise the question—is this device or test or pill really making us
healthier?—can send people into a panic. Consider the PSA test—the blood test used to screen men for
prostate cancer. The question of whether the benefits of this test outweigh the risks is one of the most
controversial issues in medicine. Some doctors worry that the test is leading to unnecessary treatment
because it catches many prostate cancers that are so slow growing, they would never be harmful if left
alone. In 2002 two medical journal editors, both doctors, made this point in an op-ed for the San Francisco
Chronicle. Gavin Yamey and Michael Wilkes wrote that since early detection hadn’t been proven through
randomized, controlled trials, to reduce a man’s risk of dying from prostate cancer, getting the test might
not be right for every man. Their op-ed, published under the headline “Prostate Cancer Screening: Is It
Worth The Pain?” did not go over so well.
Gavin Yamey: Lots of people wished that we would die.
Lisa Pollak: That’s Gavin Yamey. Since many of the readers believed the PSA test had saved their lives,
they didn’t appreciate being told that the test wasn’t effective.
Gavin Yamey: Lots of people wished that we’d have a very slow death from a nasty cancer.
People accused us of having the deaths of thousands of men on our hands for writing this piece, of
Lisa Pollak: Michael Wilkes, Yamey’s co-author:
Michael Wilkes: People wrote both to us and to our bosses, accusing us of being sort of like the
Nazis, and specifically accusing us of being like Mengele, and others accusing us of truly being
men-haters and wanting to wipe out the male population.
Lisa Pollak: When the president says we can cut health care costs by eliminating things that don’t work—
things for which there’s no evidence—it sidesteps the fact that in medicine the evidence isn’t always so
clear-cut, and that's true of the PSA test. There’s a lot more evidence about PSA now than there was when
Yamey and Wilkes wrote their op-ed. In fact, two long-awaited studies came out this spring. One showed
that the PSA test did not reduce a man’s risk of dying from prostate cancer. The other showed it reduced
prostate cancer deaths by 20%. But it also showed that for every life saved because of PSA screening, 48
other men were diagnosed and treated. In other words, for each prostate cancer death prevented, dozens of
men endured surgery and radiation, risking serious side effects like impotence and incontinence. Doctors
interpret this evidence differently. Some I talked to said it’s proof that the test saves lives; others said it
shows we might be hurting more men than we’re helping. Because the evidence is ambiguous and the
balance of risks and benefits is really a judgment call, most national guidelines say that doctors should let
men know the pros and cons of PSA testing and let them decide whether to have it. But most of the time
this is not what happens. Studies show that the majority of men get the test without any discussion at all.
It’s automatic, a no-brainer. And honestly, it’s not hard to see why. To question whether the test is
necessary, a doctor is flying in the face of all sorts of cultural forces, like the idea that if you can find
cancer early, you always should, not to mention all the billboards and free PSA screening events and
celebrities and TV ads telling men to get tested.
PSA Woman: Want to do something really special for your man this Christmas? Call his doctor
and schedule his prostate exam. Prostate exams save lives and prostates.
Lisa Pollak: Here’s another, from the NFL:
NFL Man: So get screened and don’t let prostate cancer take you out of the game.
Lisa Pollak: And of course, Larry King.
Larry King: Men over 40, take your PSA test, a simple little blood test, you get the result in a
Lisa Pollak: A few doctors I talked to mentioned another reason that physicians might be wary of bucking
the PSA trend. They told me what happened to a doctor named Dan Merenstein. Merenstein was trained in
evidence-based medicine, and about ten years ago, when he was a family practice resident, a 53-year-old
man came to him for a routine physical. Merenstein says he followed the guidelines—talked to the patient
about the benefits and risks of getting the PSA test, and the man chose not to have it. Then a year and a
half later the man went to another doctor. That doctor tested the man’s blood without discussing it with
him. His PSA level was extremely high, and a biopsy found an aggressive, incurable cancer. Now, there
was no proof that having an earlier PSA test would’ve changed the man’s fate, but Merenstein and his
residency program were sued for malpractice. At the trial the patient’s attorney argued that Merenstein
shouldn’t have given the man a choice to have the PSA test, no matter what the national guidelines said.
The attorney put other family doctors on the stand.
Dan Merenstein: And they said, “You know, we don’t talk to patients.”
Lisa Pollak: This is Dr. Merenstein.
Dan Merenstein: “That’s what they do in ivy towers; I order tests. Patients come to me for me to
order the tests. I’m the one that went to medical school, and these are the tests we order. And if
Dr. Merenstein had ordered this,” they said this under oath, “And if Dr. Merenstein ordered a
PSA, this patient would live a long, productive life, but because Dr. Merenstein failed to, this
patient is going to die shortly.”
Lisa Pollak: Merenstein was exonerated, but his residency program was found liable for $1 million. The
jury, just like the doctors on the stand, rejected the idea of following the guidelines based on evidence. To
them the best care meant doing everything you can.
Dan Merenstein: I should’ve just ordered it. There should’ve been no discussion; it shouldn’t
have been up to the patient. So that was the approach they took. And they took this approach that
this thing called evidence-based medicine is just a way to save money, just a way to ration care.
Lisa Pollak: After the trial, like a lot of doctors who’d been sued, Merenstein found it hard not to see
patients as potential plaintiffs.
Dan Merenstein: And I think, you know, you view people differently after that, and you look at
patients and you say, “This mole, which 1,000 times before I would say I’m pretty confident how
to evaluate moles and which ones I need to take off myself and which ones I think are fine to stay,
and which one to go,” I think I started sending more moles to dermatologists to remove, and
sending more people with what I was pretty confident was irritable bowel or something like that to
GI doctors to get scoped and things like that, more than I should have. It didn’t feel right.
Lisa Pollak: It didn’t feel right, he said, because he didn’t feel like he was doing what was best for the
patients. These days, when it comes to the PSA test, Merenstein starts by following the evidence. He still
tells his patients the pros and cons, but then he gives them a little nudge and adds something he never used
to. “Most people,” he tells his patients, “get the test.”
Ira Glass: Lisa Pollak. If you’re a man and you heard this story and you want to know more about the pros
and cons of getting the PSA test, there’s a good summary at the Mayo Clinic website. Those people really
know what they’re doing.
Ira Glass: Act Three. Who Would Win In A Fight Between A Polar Bear And An Insurance Company? So
if doctors aren’t going to keep costs down and patients aren’t going to keep costs down, how about
insurance companies? Of everybody in the health care system, you would think that this would be the one
group most interested in keeping costs down because they are the ones who actually make the payments to
doctors and hospitals, and every dollar they save is basically a dollar they get to keep—a dollar that goes
into their profits. Or if you want to get very technical about this, it’s a dollar less that they could charge
you and me in premiums. Well, we looked into this and it turns out that there are a lot of reasons that
insurance companies have a hard time holding down health care costs, but they all boil down to one thing:
Insurance companies are not always as powerful as you would think. The way that insurance works is that
each insurance company makes its own contract, its own deal with each local hospital group or health
provider system, and that deal spells out how much the insurance company is going to reimburse for every
different kind of procedure and test. And even in cities where a company is the biggest insurer in the
market—even then—it does not necessarily have the power to boss hospitals around and push down costs
and bargain down prices. Take as an example the pricing showdown between Blue Cross of California—a
huge insurance company—and this big network of hospitals and clinics called Sutter Health. Sarah
Koenig, another one of our producers, tells what happened.
Sarah Koenig: Back in 2000 Sutter was demanding huge rate increases from Blue Cross, averaging
something like 30 or 35%. That was a shocker. Blue Cross was the biggest insurer in the state, which
meant it was used to getting cheaper rates from hospitals than the smaller guys. But Sutter was enormous
too—it had more than 100 health care facilities all over Northern California, including more than two
dozen hospitals. Sutter had what’s called a geographic lock on the Bay Area. So of the several hundred
thousand Blue Cross customers there—
Michael Chee: Almost everybody received or knew or went to Sutter for their medical care.
Sarah Koenig: That’s Michael Chee. At the time he was spokesman for Blue Cross of California, and Blue
Cross’s position was that Sutter’s demands were out of line. They weren’t justified by the medical cost of
inflation data Blue Cross had researched. So Blue Cross offered a lower figure. Sutter rejected it, saying
Blue Cross had been underpaying them for years. It got contentious. Blue Cross still refused to pay. So
Sutter said, “If you don’t, you can tell your members to go elsewhere, find other doctors, go to other
Michael Chee: The brinksmanship that kind of occurred was, “Well, if we close our doors, all
these people, hundreds of thousands of them are going to be forced to travel an extra 30 minutes,
an extra 10 miles,” and that was not acceptable to the membership. So the membership began to
express its operation in the negotiation.
Sarah Koenig: Blue Cross got dozens, sometimes hundreds of phone calls a day, all thanks to a new
pressure tactic used by Sutter. Sutter urged its patients to call Blue Cross’s customer service line and
complain. Michael Chee and his bosses started seeing news stories about the dispute, stories that favored
Sutter. In response Blue Cross launched a major marketing push of its own to try to convince customers
everything would be okay if they would just find different doctors. Michael Chee did interviews with
reporters. He sent tens of thousands of letters to Blue Cross members, saying things like, “We are
saddened and disappointed that Sutter has put its energy into instigating members like you to contact us.”
Blue Cross bought ads in local newspapers, publishing lists of non-Sutter care centers, explaining who all
the doctors were and what they specialized in, and pointing out those facilities weren’t much farther than
Sarah Koenig: So you guys sort of mounted this campaign to try to convince your membership,
“We can do this, we can live without Sutter.” They came back to you and said…
Michael Chee: And said, “I can’t live without Sutter. We want what we want. I’ve been with my
doctor here at this location for many years and I don’t want to have to look for somebody new; I
don’t want to have to make any extra effort.”
Sarah Koenig: I mean did you explain as a company also, “This is potentially going to cost you
guys more, because your premiums are going to go up?”
Michael Chee: Absolutely, absolutely. One of the things we tried to tell members and employers
was, “This is our job. Our job is to control health care costs so that your premiums don’t
constantly go up, so that you’re not constantly paying more. And one of the ways we do that is by
the use of negotiation.”
Sarah Koenig: None of this worked. Customers didn’t budge. Neither did anybody else. State lawmakers
got dragged into the fight to mediate. Finally, because they couldn’t live without each other, Sutter and
Blue Cross worked out a compromise. Sutter didn’t get all the money it asked for. It wasn’t a 30%
increase. The actual number wasn’t made public, but they got enough that it resulted in hiked up
premiums. That’s one reason medical costs in San Francisco, where Sutter is totally dominant, are still
more expensive than cities nearby, like Oakland and San Jose, where Sutter isn’t quite as strong. So that
now a family of four in San Francisco pays $45 more per month to Blue Cross than it would pay in San
Jose for exactly the same coverage. Michael Chee is still sort of baffled that it worked out this way, that
people don’t respond to bottom line reasoning when it comes to where and how they get care. He said
costs will keep rising until we consumers start sacrificing a little, making different health care choices.
Michael Chee: Based on knowledge, based on facts, not based on our feelings, not based on what
we want. You know? Without those kinds of sacrifices, we’re always going to be stuck in this
argument of, “I want what I want, and what I want can be very expensive and not the most cost-
Sarah Koenig: As it happened, I interviewed Michael Chee from the hospital. He’d had an accident
involving one of those jet ski things and suffered a head trauma.
Michael Chee: Natasha Richardson had a very similar injury to mine. Mine was probably actually
more severe. Quite honestly I shouldn’t be talking to you right now; I should be dead.
Sarah Koenig: Michael Chee lives in Burbank, California, near Los Angeles, but he had the accident on the
Colorado River in Nevada, and was airlifted to Las Vegas for treatment. For his two-week rehab he wanted
to go home to LA and had been arguing about that with his insurance company, which happens to be Blue
Michael Chee: There are providers that I have a preference for closer to home, closer to where I
live that I wanted to go to for my care because I know them, I trust them. But my insurance would
not accommodate my medical transport from here to there because those rehab services were
available right here, without having to move me.
Sarah Koenig: But wait—weren’t you just making the exact opposite argument before, that
patients should be willing to sacrifice for lower costs and quality care?
Michael Chee: So here I am, away from home for two weeks getting my rehabilitation done. Yes.
I mean when you’re injured and you have the kind of injury that I have, you want to be close to
friends and family because it’s just more comforting. That doesn’t mean that’s a smart medical
decision; that just means that’s what I want emotionally.
Sarah Koenig: I know, I know, but hearing this, like you completely, your sympathies are
completely with the patient. You just think, “Of course you want to go home and be around your
friends and family,” and you’ve had this traumatic thing happen and it’s totally upsetting and
probably very frightening, and of course you want to go home. You know what I mean? I think
it’s a real dilemma.
Michael Chee: It is a dilemma, and I felt that, and I went through that entire emotional process,
Sarah Koenig: Do you think Blue Cross had made the right decision in your case?
Michael Chee: I think so, from a cost standpoint, yes.
Sarah Koenig: We probably can all agree that Blue Cross made the right choice in trying to save money on
Michael Chee, but we agree only in the cold light of day, and that’s what I mean by the dilemma. As
patients we don’t usually consider things in the cold light of day. It’s no wonder we don’t respond to
pocketbook arguments about how to save money on our own care. And that’s partly what makes us, the
patients, a secret weapon in these negotiations, at least for the doctors and hospitals, because we side with
them every time, because we like our doctors, we trust them, and we basically hate our insurers, even
though the insurers are paid to represent us in negotiating the price of our own care. And we unwittingly
side with the doctors in another battle we don’t even know is going on between doctors and insurers—the
one about eliminating unnecessary medical services and procedures. As you heard earlier in the show, the
Dartmouth Health Atlas estimates about a third of every health care dollar we spend is wasted on tests and
treatment we don’t need. So if health insurance companies know they’re shelling out all that money on
stuff that isn’t necessary, why can’t they do something about it? I put this to Jack Rowe, the former CEO
of Aetna, one of the biggest health insurers in the country. When he was in charge, he watched Aetna’s
expenses and its profits very, very carefully.
Sarah Koenig: Why doesn’t an insurance company go, “I want that 30-40%?” You know what I
mean? It seems like this is a lot of money sitting there that you guys could profit from. Is there
any way to get at that percentage?
Jack Rowe: Well, insurance companies are trying very hard to develop approaches which will not
only improve quality, but reduce overuse.
Sarah Koenig: So they’re trying, and it’s true. Aetna has all kinds of programs, good money-saving
programs, to promote cheaper drugs, to make sure diabetics and cardiac patients do all the preventative
things to keep them out of the emergency room. Plus Aetna, like all insurance companies, has guidelines
for new technologies they will and won’t cover, and all the scientific studies that back up that policy. But
the fact is if companies like Aetna say no too often, they risk losing customers.
Jack Rowe: And so there’s great sensitivity over that because physicians say that the insurance
companies are practicing medicine, “And who are they to tell me whether or not this patient needs
this operation?” As you recall, that’s one of the things that led to The Great Pushback.
Sarah Koenig: “The Great Pushback,” also known in the insurance industry as “The Backlash.” He’s
talking about HMOs. Back in the 1980s employers went to insurance companies and pleaded with them to
keep down costs, and that’s when the HMO came into vogue. By the mid-‘90s most employers used
HMOs to cover their employees, and it pretty much worked. Health care costs stopped rising for the first
time in a long time, and one year they even fell. But a big part of keeping costs down was tightly
controlling which doctors patients could see and denying coverage for procedures that doctors argued were
necessary. Insurance companies were inundated with complaints.
Jack Rowe: From physicians and hospitals; also from patients who were getting complaints from
physicians about their insurers; politicians also were getting complaints from doctors and hospitals
Sarah Koenig: There were dramatic stories in the press about people who’d been denied life-saving
operations. There were class-action lawsuits, legislation to limit their powers. Then there was that Helen
Hunt movie. Remember “As Good As It Gets” where she plays the mother of this poor asthmatic boy who
needed some tests he didn’t get?
Helen Hunt: They said my plan didn’t cover it and that it wasn’t necessary anyways. Why, should
Helen Hunt: [beep] HMO bastard pieces of [beep]!
Helen Hunt: I’m sorry.
Man: It’s okay. Actually, I think that’s their technical name.
Helen Hunt: [chuckles]
Sarah Koenig: Jack Rowe was one of two insurance executives I talked to who mentioned that movie. It
left a big impression on the insurance industry, because when people saw it in the theaters, they reportedly
broke into applause. As a result of those years of opposition, insurance companies will only fight doctors
and patients to a point. They don’t want to go back to the days of the HMOs, of being the hard-asses
telling everyone no, even though they did successfully hold down costs back then, and they did it without
making people sicker. There were anecdotal horror stories, for sure, but overall, as a country our medical
care didn’t suffer—we were just as healthy. But that’s not how we remember it.
Uwe Reinhardt: And now you always hear, “No one should stand between you and your doctor.”
Sarah Koenig: This is Uwe Reinhardt, a health care economist at Princeton University.
Uwe Reinhardt: You know what that means? That means no one should ever control utilization,
even if it’s unnecessary, if your doctor thinks it’s necessary. No one should ever say no. And
almost anyone who’s looked at the data says, “Oh yes, somebody should.”
Sarah Koenig: According to Reinhardt, the fact that insurers can’t completely crack down on unnecessary
procedures is just one of a whole host of reasons why the insurance industry really can’t control costs in the
American health care system right now.
Sarah Koenig: Do insurance companies actually have an incentive to keep costs down?
Uwe Reinhardt: I’ve often asked myself that question. Obviously, when you compete against
another insurers, it’s good to have lower premiums, but the insurance industry as a whole,
basically their profits tend to be 3-5% of whatever money flows through their books. So the more
money flows through the books, the more profit they make. Suppose God waved a magic wand
and said, “Okay, now, health care costs in America are half of what they are now.” Then the
insurance industry’s book of business would be half of what it is now, and therefore their profits
would be half of what it is now. It’s not totally clear to me the insurance industry would love that.
Sarah Koenig: As it stands, insurance companies are doing pretty well. They don’t make anything close to
the 30% profits of say Microsoft or Merck Pharmaceuticals, or even the ten percent profits of Exxon Mobil,
but Fortune Magazine lists the health insurance industry as the 35th most profitable industry in the country,
based on 2008 revenue. What’s the 34th most profitable industry, you ask, just above the insurers? That
would be medical facilities.
Ira Glass: Sarah Koenig. Act Four: Now What? Okay, so far this house we’ve illustrated just some of the
main things that are driving up health care costs. And truthfully, putting this show together over the last
few months, it’s been hard not to get sort of depressed. Not only do the problems seem like they’re built
into the very foundation of our health care system, but the health reform debate that’s going on right now in
Washington doesn’t seem to be about cutting costs at all. Democrats and Republicans are arguing over
who’s going to get insurance and the public option and how it’s paid for, not to mention “death panels” and
abortion, and there’s really not much discussion about how to fix the health care system as a whole to slow
the runaway costs that threaten our entire economy—the stuff we’ve been talking about all this hour. And
so to end our hour, we invited somebody who’s been following this very closely in Washington, D.C.,
Susan Dentzer. She’s been reporting on the politics and economics of health care since the 1980s for
Newsweek, and then later for US News and World Report. She’s seen HMOs come and go; she’s seen
Hillary Clinton’s health care plan come and go, and now she’s monitoring the latest attempt to remake the
health care system as the editor of a policy journal called Health Affairs. And I’ll be frank—when I sat
down with her to talk about what is actually in the bills, she totally blew my mind. We’ll get to that part in
a minute, but first the actual detail of the bills when it comes to cutting costs: There is some stuff in these
bills that addresses rising costs.
Susan Dentzer: If you are a “glass half-full” kind of person, you look at it this way: There are
some measures in the bills that would give the Secretary of Health and Human Services, among
others, enormous authority to experiment with new ways to deliver health care.
Ira Glass: This doesn’t mean little experimental projects, Dentzer says. The head of HHS will have czar-
like powers to change very basic things in how the system works, by changing how Medicare pays doctors
and hospitals. So for example, Medicare could stop paying fee for service—that system where doctors get
money for every procedure that they do. They could bundle doctors and patients into groups to cut
inefficiency and waste. The bills also set up a Medicare Commission, which could do the kind of
restructuring and cutting that would be too hot politically for Congress to do itself. Now, the weaknesses
of these bills, Dentzer says, is that they don’t force the head of HHS or anybody in the government to make
any changes at all. There are no deadlines. And the amount that’s going to get saved if everything goes
perfectly, according to the Congressional Budget Office, is much smaller than health care costs are going to
rise. But the idea is that Medicare is such a huge part of the health care system—it pays for a fourth of all
the health care in the country; it’s the biggest insurer in America—changes made in Medicare will be
adopted by others.
Susan Dentzer: So the notion is to really create a platform for gradual change.
Ira Glass: And is part of the impulse behind this basically to say like, “We are not going to agree
in the Senate and the House on the exact ways to cut costs and exactly which things to do, and so
like let’s just agree somebody’s going to do that. It’s going to be the head of the Department of
Health and Human Services,” and some of these other things that you’re saying, “But let’s not
discuss that here.”
Susan Dentzer: Yes. That’s part of it. And the other realistic piece of this is if you tried to build
all of this into the bill right now, if you said, “We’re going to make sweeping changes in the
system; we’re going to completely pay you in a totally different way; we’re going to take you
doctors who’ve been out in the hinterlands, collecting your fee for service monies, and basically
restructure the system in such a way that you might have to live your life really differently.” Just
try putting that into a bill that gets everybody to accept it—you can’t.
Ira Glass: Susan Dentzer told me that there are people in the administration who are deeply involved in the
details of how to cut health care costs, and she talks to them. But she says they don’t talk about this stuff
much publicly for similar reasons—it’s a political loser. It’s a tough sell to say to people, “Not only will
you get less health care; you’ll be better off.” Okay, now I’m going to tell you the thing that Susan Dentzer
says that totally shocked me. She told me that for the first time since she’s been covering health care,
decades ago, all the major players in health care—the hospitals, the insurance companies, the doctors—she
says they are all, for the first time, agreeing that something has to change. And she says this is the biggest
political achievement made in health reform so far.
Susan Dentzer: Almost all the stakeholders in health care have been at the table and are talking
about all of this. They know that the system cannot persist the way it is, that we’ve got to do
things differently, we have got to get more value out of the dollars spent on health care.
Ira Glass: How recent is that agreement? Is that because of Obama and his people saying, “Okay,
here’s what we’re going to do?”
Susan Dentzer: Not really. We’d probably be at this juncture no matter who had been elected
president, because of what was happening to the cost over the course of this decade.
Ira Glass: Right, there was just a growing consensus, like it’s going up so fast.
Susan Dentzer: Well, health insurance premiums went up 130% from the year 2000 to now. Two
years ago I was talking to an insurance executive from one of the leading insurance companies,
and I said, “Okay, so what’s the situation like? And draw me the analogy with the threat alert
system. You know, red alert, orange, green, whatever.” He said, “We’re on red alert. We’re on
red alert. The system is falling apart.”
Ira Glass: The insurance companies?
Susan Dentzer: Yes.
Ira Glass: I’m just surprised to hear the insurance companies are on red alert, because they are still
making nice profits, you know?
Susan Dentzer: But they can see the handwriting on the wall. They see the system crumbling.
And they also see, they understand the pressures that will ensue if things get really out of hand. I
mean just imagine if we had had 100 million people uninsured, the kind of pressures there
would’ve been for say a single payer system. They know that. They think the only solution now
for preserving any part of the system as a private system is to stop the bleeding now.
Ira Glass: And so in addition to the health care reform happening in Washington, Susan Dentzer says
there’s a second reform that’s happening right now all over the country—hospitals and health care
providers and state legislatures coming up with their own ways to restructure and contain costs. And that’s
what gives her hope—that things are so hopeless for every player across the board, that a consensus is
actually taking hold that things can’t continue as they have. And she sees people and organizations taking